Total Vaginal Hysterectomy

 

Patient Name: @name@

MRN: @mrn@

Procedure Date: @td@

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Preoperative diagnosis:

1. @age@ yo @gp@ with *** who agrees to proceed with definitive management with total vaginal hysterectomy

Postoperative diagnosis:

1. same 

Procedure:

1. Total vaginal hysterectomy

2. ***

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Attending: ***

Assistants:***

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Anesthesia: GETA

Estimated blood loss: ***

IVF fluid: ***

Urine output: *** via foley catheter

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Complications: none

Specimens:

1. Uterus, cervix

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Findings:

• Normal appearing uterus and cervix

• Ovaries palpated normally bilaterally

• ***Normal cystoscopy at the start of procedure with bilateral ureteral jets

• ***Normal cystoscopy after hysterectomy no injury to the bladder or urethra

• Normal rectal exam at the completion of hysterectomy, ***placement of sacrospinous sutures and at the completion of the procedure with no injury to the rectum, no tensioning or tethering of the rectum and no suture material in the rectum. 

• Good hemostasis at the completion of the procedure

• Sponge, needle and instrument counts correct

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Indications:

@age@ year old @gp@ with ***. The patient decided to undergo surgical management of this problem. Risks, benefits, indications and alternatives of the procedure were reviewed with the patient. Risks reviewed include bleeding, infection, damage to bladder, ureter, urethra, bowel, blood vessels, nerves, post-operative urinary retention and post-operative urinary incontinence. All questions answered and informed consent obtained.

 

Procedure:

On the day of surgery the patient was identified in the preoperative waiting area. Informed consent was again reviewed. The patient expressed understanding and desired to continue with the procedure. ***Pre-operative heparin, tylenol and gabapentin were administered. The patient was then taken to the operating room. Pneumatic compression devices were placed on her lower extremities bilaterally. IV antibiotics were given and general anesthesia was induced without difficulty. Time out was taken to identify the patient and procedure. The patient was prepped and draped in the usual fashion in dorsal lithotomy position with Allen stirrups. Exam under anesthesia demonstrated ***. ***Cystoscopy was then performed. Normal findings in the bladder and bilateral ureteral jets noted. 

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The vaginal hysterectomy was performed as follows: The cervix was grasped with Allis clamps. The cervix was then infiltrated circumferentially with ***0.25% marcaine with epinephrine. An incision was made circumferentially at the cervicovaginal junction and vaginal mucosa dissected cephalad sharply with scissors. Bilaterally pericervical tissue was clamped with Heaney clamps, transected and suture ligated with 0-Vicryl in several bites, between which the vaginal mucosa anteriorly and posteriorly reached the peritoneal reflections. The posterior peritoneum was entered ***while digital rectal exam performed to confirm limits of rectum and avoid injury. Anteriorly the vesicouterine peritoneal fold was identified and incised with Metzenbaum scissors. Once entry into the peritoneal cavity was achieved, a curved deaver was placed. The uterosacral ligaments were bilaterally clamped with Heaneys, cut, and suture ligated with #0 Vicryl suture. Bilaterally the cardinal and broad ligaments including the uterine arteries were sequentially clamped, transected and suture ligated with 0-Vicryl. The utero-ovarian ligaments were reached. Heaney clamps were placed across the uteroovarian ligament, cut, and free-tied, then suture ligated with a #0-Vicryl bilaterally. The uterus and cervix were removed from the field and sent to pathology. All pedicles were inspected; there was good hemostasis. Ovaries bilaterally were palpated small and normal. The vaginal cuff was closed in a series of figure of eights with 0-Vicryl.

 

***Cystoscopy was performed and demonstrated no injury and stents remained in place.

Foley catheter was replaced.

 

***The anterior vaginal repair and sacrospinous ligament fixation was performed as follows. Two Allis clamps were placed on the midline anterior vaginal mucosa at the level of the bladder neck and near the cuff, respectively. This area of anterior vaginal mucosa was then infiltrated with local anesthetic diluted 1:1 with injectable saline. A midline mucosa was incised with knife. The vaginal mucosa was dissected free from the underlying fibromuscular tissue bilaterally using metzenbaums scissors. Using careful blunt dissection, the dissection was carried to the bilateral sacrospinous ligaments. After the ligament was cleared bilaterally, two 0-Maxon sutures were placed in the sacrospinous ligament, approximately 1-2 cm from the spine on the patient's right with the Capio device. An additional 0-Maxon suture was placed in the sacrospinous ligament on the left in a similar fashion. Rectal exam confirmed no suture entry into the rectum. Interrupted stitches of #2-0 Maxon were used to plicate fibromuscular tissue in midline of the anterior vaginal wall, thus reducing the cystocele. Excess vaginal mucosa was trimmed and removed. The sacrospinous ligament sutures were then passed into the bilateral corners of the vaginal cuff and held. Vaginal mucosa was closed with an interrupted stitch of #3-0 Vicryl. Cystoscopy was repeated and confirmed no suture entry into or injury to the bladder or urethra. Bilateral ureteral stents remained in place.

Foley catheter replaced. The sacropsinous ligament sutures were then tied down, elevating the vaginal cuff in a cephalad direction. Excellent support appreciated and decision made no posterior repair was necessary, particularly given the difficult dissection posteriorly for the hysterectomy. Repeat rectal exam confirmed no injury to the rectum, no suture material in the rectum, no tethering of the rectum.

 

Foley catheter and stents were removed. Cystoscopy was repeated and demonstrated no evidence of injury to the bladder or urethra. Repeated ureteral jets were noted from the left UO, none from the right. Peristalsis appreciated but no efflux. Several sutures removed from the vaginal mucosal closure over the anterior repair. Several plication sutures of the anterior repair removed with subsequent cystoscopy that did not demonstrate efflux from the right UO. Urology was consulted for assessment of the ureters. The anterior repair plication sutures were replaced with 2-0 Maxon suture to plicate the fibromuscular tissue in the midline and reduce bulge. The vaginal mucosa closed in a running fashion with 3-0 Vicryl suture.

The foley catheter replaced after completion of their portion of the procedure.

The patient was awakened, extubated and sent to the recovery room in stable condition. Sponge, needle and instrument counts were correct x 2.

 

Dr. ***, attending physician, was present and involved in all aspects of the above procedure.